Will We Improve Healthcare Delivery By Building Hierarchies or Loose Networks? Considering Lunch Delivered in Mumbai

When you talk to patients about improving the “patient experience”, the conversation usually steers to how patients move between episodes of care; how information is shared; how scheduling works or doesn’t; how test results are lost and wait times are long. It’s rarely the science of medicine that antagonizes patients, but rather the lack of functional systems. I was reflecting on this problem this morning when I heard the extraordinary story of how lunch is delivered daily to thousands of people living in Mumbai.

In Mumbai, Dabbawalas are deliverymen who collect tin containers of homemade food (“dabbas”) from homes and deliver them using trains and bicycles to workers at lunchtime across Mumbai. They then return the empty tin carriers back home once the meal is over. The Dabbawalas use a system of codes written on each tin (see photo below) to identify where the they come from and where they should go. 5,000 Dabbawalas process 175,000 “dabbas” a day and (the often poorly literate) Dabbawalas make next to no delivery errors: according to Jim (and Wikipedia) the rate of delivery errors is in the range of 1 in 6-8 million deliveries. The system is so robust, in fact, that it has earned an ISO-9001 rating and Fedex reportedly sends teams to learn from the system.

I’m not sure what to make of this remarkable feat. On one hand food delivery isn’t nearly as complex as healthcare. On the other, there is an extraordinary degree of variability and customer contact in the Dabbawala system (175,000 people in 175,000 homes sending 175,000 lunches to 175,000 people at 175,000 offices daily using 5,000 Dabbawalas) which still results exponentially lower rates of failure than even well-managed healthcare.

Something inherent to the Dabawalla system keeps the error rate so low, and I don’t think it’s rigid adherence to strict protocols. My suspicion is that the highly “networked” nature of the delivery system makes it much more resistant to disruptions than a hierarchical systems such as the ones we try to impose in healthcare as systems consolidate and standardize—much in the way that the internet allows for optionality of data flow around obstructions. Strong local knowledge and personal understanding of the customer likely contribute as well.

My friend Dr. Mike Hein, a great healthcare thinker, often bemoans healthcare’s seeming desire to stamp out variation and to create the “McDonalds burger of care”. In a recent thoughtful blog, he suggests that administrator’s instincts to create large, hierarchical and standardized monolithic healthcare companies as healthcare coalesces is outdated and counterproductive.

…management does what management is; they set more explicit goals, increase performance metrics like breeding rabbits, design ‘stretch’ targets, deploy pay-for-performance ‘incentives,’ and craft more and more policies and procedures. They drive for tighter control of the unwieldy, pulling power and decision-making ever more central, believing that this will decrease the variation that they see and don’t fully understand. These actions eventually consolidate ‘leadership’ positions centrally (management), drive the front line employees into unhappy disengaged automatons, subsequently decreasing ownership of their local work processes.

Dr Hein and I could have a long debate about where standardization works and doesn’t work in healthcare. I’m a believer in locking in the basics through processes such as LEAN so that there is time to focus on productive variability; but I’m increasingly suspicious that thoughtful and organic complexity at the front lines might be a counterintuitive solution to improving care delivery. After all, many observers have suggested that the Dabbawalas have such low rates of error that they actually meet the criteria for becoming a six-sigma organization— fewer than 3.4 defects per million defect free processes.

Loosely managed, informal and highly networked systems might just be a path forward.

“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.